


SOAP Note

by shell



Category: due South
Genre: M/M, Slash, documentation challenge
Language: English
Status: Completed
Published: 2003-06-21
Updated: 2003-06-21
Packaged: 2017-10-02 05:32:33
Rating: General Audiences
Warnings: No Archive Warnings Apply
Chapters: 1
Words: 390
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/3104
Author URL: https://archiveofourown.org/users/shell/pseuds/shell
Summary: <blockquote class="userstuff">
              <p>Just what it says.</p>
            </blockquote>





	SOAP Note

**Author's Note:**

> S: Subjective  
> O: Objective  
> A: Assessment  
> P: Plan  
> Beta thanks to maubast and Ardent. For the documentation challenge at due South Flashfiction.

Pt's Name: Ray Kowalski MR# 966534  
7/12/03 4:30 pm

S: 43 yo WM presents for annual physical. Denies probs/questions.  
Med. Hist.: Usual childhood diseases. + frostbite L great toe 1998, no amputation. + broken arm age 8; broken nose age 20; gunshot to abdomen, 1989; dogsled accident 2000 (stitches R leg, no broken bones).  
Surg: Abdominal (remove bullet) 1989, no complications, no probs. with anesthesia.  
Hosp: 1989, see above.  
Fam. Hist.: + HTN (F, PGF, PGM), + prostate cancer (MGF), + breast cancer (MGM), + DM (PGM), + osteoarthritis (PGF, PGM, MGM).  
Social Hist.: Imm. from US in 1998 to be with current partner, who is RCMP officer. Works in snowmobile repair and "odd jobs." Former police officer. Ed: 14 years. Divorced; going to Toronto in 2 wks to marry current (m) partner.  
Sex. Hist: Bisexual; has been with current partner x 5 yrs. Uses condoms. States he and partner have both been tested and are HIV negative.  
Denies phys/sex abuse.  
Allergies: NKMA; environmental (cats).  
Exercise: dogsledding, snowshoeing, walking.  
Denies smoking/drugs, states occ. beer.  
Meds: Occ. ibuprofen or tylenol; states occ. uses salve made by partner for sore muscles/joints.  
24 hour diet recall: coffee with smarties, cereal with milk, pizza. States eats better when partner is not on patrol.

O: BP 126/74, P 85, T 97.9 oral, RR 16  
Ht: 5'11 Wt: 160 BMI 22  
Gen'l: Pleasant, thin, no apparent distress.  
HEENT: Wears glasses, otherwise WNL, no thyromegaly, no lympadenopathy. Teeth in good repair.  
Heart: RRR; S1, S2; no murmur.  
Lungs: Clear to auscultation, resp. easy &amp; unlabored.  
Neuro: Grossly intact; reflexes +3 bilat.  
Skin: Pink, warm; scar L great toe, R thigh, lower R abdomen. No varicosities. Tattoos R shoulder, L hip.  
Abd: NT, no organomegaly. Surgical/gunshot scar well approximated, no keloids.  
Back: No scoliosis, - CVAT.  
Extremities: Normal ROM; - Homan's; + crepitus bilat. knees. No clubbing of fingers, capillary refill &lt;3 sec.  
Genitalia: Normal male, testes non-enlarged, symm., no masses, no hydrocele.  
Rectal: prostate NT, non-enlarged; guaiac -.

A/P: Phys. exam WNL except mild arthritis both knees.  
Advised cont. weight bearing exercise, good diet, incr. protein and calcium intake, importance of incr. intake in this climate. Given info on testicular self-exam, revised food pyramid. Advised biannual PSA due to family history of prostate cancer.  
Labs: PSA, CBC, lipid profile.  
RTC 1 year and prn.

\--C. Maclean, NP, MS


End file.
